Innovations in Assessing ADHD: Development, Psychometric Properties, and Factor Structure of the ADHD Symptoms Rating Scale (ADHD-SRS)

This research involved the development of a behavior rating scale designed to measure ADHD and the investigation of the scale's psychometric properties and factor structure. This scale, the ADHD Symptoms Rating Scale (ADHD-SRS), was developed for the assessment of ADHD in the school-age (K–12) population. Participants were 1006 children and adolescents (in grades K–12) who were rated by their parents and/or teachers. The results indicate that the ADHD-SRS possesses strong internal consistency reliability and test–retest reliability and moderate cross-informant reliability. The data also suggest that the ADHD-SRS has strong content validity. Convergent validity of this instrument was also high, as demonstrated by correlations with three previously validated behavior rating scales. Significant age and gender differences in ADHD symptoms were found with both the parent and teacher respondent populations. Finally, the factor analysis of the ADHD-SRS suggested a two factor oblique rotation as the best fit for both the parent and the teacher data. After a visual inspection of the items which loaded on each factor, Factor 1 was named Hyperactive-Impulsive and Factor 2 was named Inattention. These two factors, along with the items which loaded on each factor, appear to be remarkably similar to the two categories listed in the DSM-IV for ADHD. Directions for future research, as well as clinical implications and limitations of the research are discussed.     

Executive Functioning, Temporal Discounting, and Sense of Time in Adolescents with Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD)

Clinic-referred teens (ages 12–19) with ADHD and ODD (N = 101) were compared to community control (CC) teens, equated for age and sex, (N = 39) on a variety of psychological tasks assessing executive functioning (EF), temporal reward discounting, and time estimation and reproduction. A factor analysis reduced the EF measures to three dimensions, representing CPT Inattention, Working Memory, and CPT Inhibition. Results indicated that the ADHD group had significantly more CPT Inattention than the CC group. No differences were found for Working Memory or CPT Inhibition. The ADHD group displayed significantly greater temporal discounting of delayed hypothetical monetary rewards relative to immediate ones and manifested more impaired time reproduction, but not time estimation, than did the CC group. Main effects for level of IQ were found only on the Working Memory factor and largely did not interact with the group factor otherwise. The group differences in CPT Inattention, temporal discounting, and time reproduction were not a function of level of comorbid oppositional defiant disorder, delinquency, or anxiety–depression. Results are reasonably consistent with past research on EF and sense of time in children with ADHD and extend these findings to the adolescent age group. Problems with working memory and CPT inhibition found in prior studies of children with ADHD, however, were not evident here, perhaps owing to age-related improvements or insufficient task difficulty.     

Treatment Sensitivity of a Brief Rating Scale for Attention-Deficit Hyperactivity Disorder (ADHD) Symptoms

This study examined the treatment sensitivity of the ADHD Questionnaire (ADHD-Q), which is a brief rating scale for measuring symptoms of inattention, hyperactivity, and impulsivity in children. Parent, teacher, and child self-report data of the ADHD-Q were obtained for 17 clinically referred children with ADHD on the three occasions: (1) during the regular intake assessment, (2) just before the start of the stimulant medication (i.e., methylphenidate) intervention, and (3) four weeks after the start of the medication intervention. Results showed that ADHD-Q scores remained fairly stable in the period prior to the intervention, but then showed a substantial decline after the stimulant medication had been administered. Clearly, this finding supports the treatment sensitivity of the ADHD-Q.     

Revision and Restandardization of the Conners Teacher Rating Scale (CTRS-R): Factor Structure, Reliability, and Criterion Validity

The Conners Teacher Rating Scale (CTRS) is a commonly used research and clinical tool for assessing children's behavior in the classroom. The present study introduces the revised CTRS (CTRS-R) which improves on the original CTRS by (1) establishing normative data from a large, representative North American sample, (2) deriving a factor structure using advanced statistical techniques, and (3) updating the item content to reflect current conceptualizations of childhood disorders. Using confirmatory factor analysis, a six-factor structure was found which includes Hyperactivity-Impulsivity, Perfectionism, Inattention/Cognitive Problems, Social Problems, Oppositionality, and Anxious/Shy factors. The reliability of the scale, as measured by test-retest correlations and internal consistency, is generally satisfactory. Using all of the scale factors to discriminate between attention deficit hyperactivity disordered and normal children, 85 percent of children were correctly classified, supporting the validity of the scale and indicating excellent clinical utility. Similarities and differences between the original CTRS factor structure and the CTRS-R factor structure are discussed.     

The Revised Conners' Parent Rating Scale (CPRS-R): Factor Structure, Reliability, and Criterion Validity

The Conners' Parent Rating Scale (CPRS) is a popular research and clinical tool for obtaining parental reports of childhood behavior problems. The present study introduces a revised CPRS (CPRS-R) which has norms derived from a large, representative sample of North American children, uses confirmatory factor analysis to develop a definitive factor structure, and has an updated item content to reflect recent knowledge and developments concerning childhood behavior problems. Exploratory and confirmatory factor-analytic results revealed a seven-factor model including the following factors: Cognitive Problems, Oppositional, Hyperactivity-Impulsivity, Anxious-Shy, Perfectionism, Social Problems, and Psychosomatic. The psychometric properties of the revised scale appear adequate as demonstrated by good internal reliability coefficients, high test-retest reliability, and effective discriminatory power. Advantages of the CPRS-R include a corresponding factor structure with the Conners' Teacher Rating Scale—Revised and comprehensive symptom coverage for attention deficit hyperactivity disorder (ADHD) and related disorders. Factor congruence with the original CPRS as well as similarities with other parent rating scales are discussed.     

Parent and Teacher Ratings of Attention-Deficit/Hyperactivity Disorder in Preschool: The ADHD Rating Scale-IV Preschool Version

Efforts for early identification and intervention for children with AD/HD have necessitated the development of rating scales of behavior for the preschool population. The standardization, reliability, and validity data were presented for the ADHD Rating Scale-IV Preschool Version. Parent and teacher ratings were collected on 902 and 977 children 3 to 5 years of age, respectively. Raw scores for the Inattention, Hyperactivity/Impulsivity and Total scores were converted to T-Scores and percentile ranks. Reliability coefficients ranged from 0.80 to 0.95 indicating good test–retest reliability. Concurrent validity with the Conners Teacher Rating Scales: Revised-Short and Conners Parent Rating Scale: Revised-Short ranged from 0.54 to 0.96. The ADHD-Rating Scale-IV appears to be a reliable, valid and user friendly measure for screening preschoolers with behavior problems. Future research is needed to validate its widespread use as a screening and diagnostic tool.     

Confirmatory factor analysis of the Behavior Rating Inventory of Executive Function (BRIEF) in a clinical sample.

Evidence for the validity of the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) based on internal structure was examined in a sample of children with mixed clinical diagnoses via maximum likelihood confirmatory factor analysis. Four alternative factor models of children's executive function, based on current theories that posit a unidimensional versus fractionated model (Rabbitt, 1997; Shallice & Burgess, 1991), using the revised 9-scale BRIEF configuration that separates two components of the Monitor scale, were examined for model fit. A 3-factor structure best modeled the data when compared directly with 1-, 2-, and 4-factor models. The 3-factor model was defined by a Behavior Regulation factor consisting of the BRIEF Inhibit and Self-Monitor scales, an Emotional Regulation factor consisting of the Emotional Control and Shift scales, and a Metacognition factor composed of the Working Memory, Initiate, Plan/Organize, Organization of Materials, and Task-Monitor scales. The findings support a fractionated, multi-component view of executive function as measured by the BRIEF.     

Long-Term Executive Function Deficits in Children With Traumatic Brain Injuries: Assessment Using the Behavior Rating Inventory of Executive Function (BRIEF)

Long-term deficits in executive functions following childhood traumatic brain injuries (TBI) were examined using the Behavior Rating Inventory of Executive Function (BRIEF). Parents completed the BRIEF approximately 5 years postinjury as part of a prospective study of children injured between the ages of 6 and 12. The children were between 10 and 19 years of age at the time of the assessment, and included 33 with severe TBI, 31 with moderate TBI, and 34 with orthopedic injuries. Parents also rated children's adaptive functioning and completed several other measures of parent and family functioning. Children were administered a neuropsychological test battery that included several measures of executive functions. The groups displayed a significant linear trend in BRIEF scores, with the largest deficits in executive functions reported in children with severe TBI. BRIEF scores were related consistently across groups to a test of working memory, but not to other neuropsychological measures. BRIEF scores also predicted children's adaptive functioning and behavioral adjustment, as well as parent psychological distress, perceived family burden, and general family functioning. The findings indicate that TBI results in long-term deficits in executive functions that are related to children's psychosocial outcomes, as well as to parent and family functioning.     

Assessment of executive function in ADHD adolescents: contribution of performance tests and rating scales

This study aimed to analyze performance on measures of neuropsychological and behavioral executive functions (EF) in adolescents with attention deficit hyperactivity disorder (ADHD), and to evaluate the utility of performance-based tests for predicting scores on behavioral EF ratings. One hundred eighteen adolescents (75 ADHD and 43 controls) aged 12–16 years performed neuropsychological tests and completed a behavior rating scale of EF. The ADHD group presented significantly lower scores than controls on Full Scale IQ (FSIQ) and all indexes of the WISC-IV, except the verbal comprehension index (VCI). The ADHD group had significantly lower scores on performance-based tests of working memory, planning and inhibition, and on EF rating scales. Scores on the cognitive EF working memory, planning and flexibility modestly predicted performance on behavioral EF. The results suggest that the combined use of performance-based tests and rating scales provides valuable complementary information that can improve the assessment of executive domains in ADHD.     

Theory of Mind and Executive Functions in Young Bilingual Children

Few studies have explored the relationship between theory of mind (ToM), executive function (EF), and bilingualism at the same time. In this study 14 young bilingual children were compared with monolingual children on a test battery composed of 5 ToM tests, 5 EF tests, and 1 test of general language ability. The result showed that despite significantly lower verbal ability, the bilingual children outperformed the monolingual ones on tests of EF. There were no differences in ToM performance. The authors argue that there is a strong relationship between bilingualism and EF, but, contrary to results from earlier studies, they could not find any relationship between bilingualism and ToM. EF did not predict ToM performance. Lack of a significant relationship could be due to the children's young age and consequently their low scores on the ToM tasks.     

Written expression in boys with ADHD: The mediating roles of working memory and oral expression

The written expression difficulties experienced by children with ADHD are widely recognized; however, scant empirical evidence exists concerning the cognitive mechanisms and processes underlying these deficiencies. The current study investigated the independent and potentially interactive contributions of two developmentally antecedent cognitive processes – viz., working memory (WM) and oral expression – hypothesized to influence written expression ability in boys. Thirty-three boys with ADHD-Combined Presentation and 27 neurotypical (NT) boys 8–12 years of age were administered standardized measures of oral and written expression, and multiple counterbalanced tasks to assess WM central executive (CE) processes, WM phonological short-term memory (PH STM), and WM visuospatial short-term memory (VS STM). Bias-corrected bootstrapped mediation analyses revealed a significant mediation effect, wherein the independent and interactive effects of PH STM and oral expression collectively explained 76% of the diagnostic status to written expression relation. The implications of the obtained results for clinical practice suggest that children with ADHD may benefit by incorporating a blended approach that simultaneously strengthens PH STM capacity and oral expression abilities as antecedents to engaging in writing-related activities.     

Nicotine exposure effects on ADHD in young adults with Attention Deficit Hyperactive Disorder (ADHD)

This study investigated whether ingestion of nicotine could enhance cognitive performance in people with ADHD. Participants with ADHD (n = 17) and without ADHD (n = 22) were contrasted for nicotine use. Cognitive performance was measured using selected subtests of the Cambridge Neuropsychological Test Automated Battery (CANTAB). Baseline cognitive performance data were collected prior to experimental nicotine exposure. The ADHD group with nicotine exposure performed significantly better than the non-exposure group post-intervention. Nicotine exposure appears to boost cognitive performance in subjects with ADHD.     

Evaluation of executive functions in children and adolescents with familial Mediterranean fever

The aim of the present study was to investigate neuropsychological test performance in children and adolescents with familial Mediterranean fever (FMF). A total of 88 children and adolescents aged 8 to 17 years were included, 52 with FMF and 36 healthy controls. After the participants were administered the Children Depression Inventory (CDI) and the Screen for Child Anxiety Related Emotional Disorders (SCARED), they completed the battery tests of the Central Nervous System Vital Signs (CNSVS), a neurocognitive test battery, via computer. The battery calculates seven domain scores (Memory, Psychomotor Speed, Processing Speed, Reaction Time, Complex Attention, Executive Function, and Cognitive Flexibility) and a summary score (Neurocognition Index [NCI]). A statistically significant difference between the FMF and control groups was found in six out of seven domains, where the scores of the participants with FMF were found to be significantly lower than those of the control participants (p < .05). Although the mean Reaction Time score of the participants with FMF was found to be lower than that of the control participants, the finding was not statistically significant (p > .05). The mean CDI and SCARED scores of the participants with FMF were found to be significantly higher than those of the control participants (p < .05). Low scores in the Processing Speed and Psychomotor Speed domains of the CNSVS were significantly correlated with higher SCARED scores (r = ?.37, p = .01). Impaired cognitive functions should be taken into consideration in children and adolescents with FMF when assessing and managing this population.     

Psychometric characteristics of a multidimensional measure to assess impairment: The Child and Adolescent Functional Assessment Scale

The Child and Adolescent Functional Assessment Scale (CAFAS) is a multidimensional measure of degree of impairment in functioning. Interrater reliability data are presented for lay raters, graduate students, and frontline staff. Reliability was high for the total score and behaviorally-oriented scales. Construct, concurrent, and discriminant validity were assessed with the sample of children and adolescents evaluated at the Fort Bragg Demonstration Evaluation Project. Youth and their caregivers were evaluated via interview and selfcompleted instruments at four time points. Significant correlations were found between the CAFAS and other related constructs. Concurrent validity was demonstrated by logistic regression analyses examining the relationship between CAFAS ratings and problematic behaviors endorsed on measures completed by parents, teachers, or the youth. Youth with higher CAFAS total scores were much more likely to have poor social relationships, difficulties in school, and problems with the law. Discriminant validity was assessed with a repeated measures analysis of variance with intensity of care at intake and time as factors. Youth who were inpatients or in residential treatment centers at intake had higher CAFAS scores than those who were outpatients. These findings provide strong evidence for the reliability and validity of the CAFAS.     

The Executive Functions and Self-Regulation: An Evolutionary Neuropsychological Perspective

Neuropsychology Review - Neuropsychology has customarily taken a molecular and myopic view of executive functioning, concentrating largely on those proximal processes of which it may be comprised....     

Assessing Stress in Families of Children with ADHD: Preliminary Development of the Disruptive Behavior Stress Inventory (DBSI)

This paper describes the initial development of the Disruptive Behavior Stress Inventory (DBSI). This 40-item measure, which provides indices of the number of stressors experienced during the past 6 months and the rated stressfulness of these events, is designed to assess behavior-related family stress experienced by families of children with attention-deficit/hyperactivity disorder (ADHD). Findings provide strong support for the internal consistency of the DBSI and suggest adequate test-retest reliability. Support for the validity of the measure is suggested by findings that DBSI stress indices differentiate between parents of children with ADHD and those with no history of this disorder. Additional support is provided by findings that scores on the DBSI also differentiate between parents of children with ADHD, combined type and parents of children with ADHD, inattentive type. It is suggested that this measure may provide useful clinical information regarding stress levels in families of children with ADHD and that it may be of potential value as an ADHD treatment outcome measure.     

Confirmatory Factor Analysis of the Behavior Rating Inventory of Executive Function (BRIEF) in a Clinical Sample

Evidence for the validity of the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) based on internal structure was examined in a sample of children with mixed clinical diagnoses via maximum likelihood confirmatory factor analysis. Four alternative factor models of children's executive function, based on current theories that posit a unidimensional versus fractionated model (Rabbitt, 1997; Shallice & Burgess, 1991), using the revised 9-scale BRIEF configuration that separates two components of the Monitor scale, were examined for model fit. A 3-factor structure best modeled the data when compared directly with 1-, 2-, and 4-factor models. The 3-factor model was defined by a Behavior Regulation factor consisting of the BRIEF Inhibit and Self-Monitor scales, an Emotional Regulation factor consisting of the Emotional Control and Shift scales, and a Metacognition factor composed of the Working Memory, Initiate, Plan/Organize, Organization of Materials, and Task-Monitor scales. The findings support a fractionated, multi-component view of executive function as measured by the BRIEF.     

Working Memory Deficits in Boys with Attention-deficit/Hyperactivity Disorder (ADHD): The Contribution of Central Executive and Subsystem Processes

The current study investigated contradictory findings from recent experimental and meta-analytic studies concerning working memory deficits in ADHD. Working memory refers to the cognitive ability to temporarily store and mentally manipulate limited amounts of information for use in guiding behavior. Phonological (verbal) and visuospatial (nonverbal) working memory were assessed across four memory load conditions in 23 boys (12 ADHD, 11 typically developing) using tasks based on Baddeley's (Working memory, thought, and action, Oxford University Press, New York, 2007) working memory model. The model posits separate phonological and visuospatial storage and rehearsal components that are controlled by a single attentional controller (CE: central executive). A latent variable approach was used to partial task performance related to three variables of interest: phonological buffer/rehearsal loop, visuospatial buffer/rehearsal loop, and the CE attentional controller. ADHD-related working memory deficits were apparent across all three cognitive systems--with the largest magnitude of deficits apparent in the CE--even after controlling for reading speed, nonverbal visual encoding, age, IQ, and SES.     

Methodological Issues in the Assessment of Medication Effects in Children Diagnosed with Attention Deficit Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed disorders in school-aged children and is usually treated with stimulant medications, including methylphenidate (MPH; Ritalin®, Ritalin-LA®, Concerta®, Metadate®, or Focalin®) and other drug compounds (e.g., Adderall®, Adderall-XR®, or Dexedrine). Assessment of school behavior and performance is a critical component in determining the safety and efficacy of these medications. This paper reviews methodological issues in assessing drug effects in school settings by considering features of the independent variable (the medication), the dependent variables (the endpoints selected for assessment), and the design (the structure of the assessment). In addition, we consider recent conceptual advances in understanding the behavioral mechanisms of action of drugs used to treat ADHD that may influence the structure and interpretation of medication assessments.